Provider Demographics
NPI:1538834619
Name:IRVIN, ETHAN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:IRVIN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 MEDICAL CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27531
Mailing Address - Country:US
Mailing Address - Phone:919-722-1802
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST BLDG 700
Practice Address - Street 2:
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-497-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider